Hospital Chronicles (E-Journal)
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Electrical Storm 11 Years After ICD Implantation in a Patient With Dilated Cardiomyopathy: the Role of RF Ablation
No full textThe case of a 59-year-old patient is presented who had received an ICD 11 years earlier due to syncopal VT and now sustained multiple episodes of VT within a few hours. This electrical storm was managed with combined triple antiarrhythmic drug therapy followed by electrophysiological substrate modification via catheter ablation guided by electroanatomical mapping in the EP lab.The case of a 59-year-old patient is presented who had received an ICD 11 years earlier due to syncopal VT and now sustained multiple episodes of VT within a few hours. This electrical storm was managed with combined triple antiarrhythmic drug therapy followed by electrophysiological substrate modification via catheter ablation guided by electroanatomical mapping in the EP lab
Transcatheter Closure of Secundum Atrial Septal Defect Using the Amplatzer Device: Single Center Experience in 140 Patients
Get PDFIn this paper we present our experience with the Amplatzer septal occluder device, employed in 140 patients for percutaneous closure of atrial secundum defect (ASD), from October 2002 to February 2006. The age of patients ranged between 5.3 and 70 years, median 21.9 years. Procedure time ranged between 25 and 240 minutes, median 60 minutes; fluoroscopy time ranged between 3.5 and 45 minutes, median 12 minutes. Transoesophageal echocardiography was used to monitor the implantation procedure. The size of the selected device was 1 to 2 mm larger than the stretched diameter of the defect and ranged between 6-40 mm. Two devices have been implanted in two patients. Serious procedure related complications (embolization and perforation of the left atrial wall) occurred in two cases. At follow up (10 days to 3.4 years, median 2.3 years) complete closure was documented in 97% of this patient group. Unrecognized during implantation, but detected after release, small additional defect with trivial residual shunt was documented in 4 patients. A young critically ill patient, cyanotic due to right-to-left shunt, with complex congenital heart disease developed a brain abscess three months after implantation. In conclusion, percutaneous ASD closure with use of the Amplatzer device in this patient cohort was highly successful with a low complication rate
Hypertension Guidelines: What is Expected to Change in 2006
Get PDFEvidence-based medicine suggests that practice hypertension guidelines should be primarily based on the evidence from large outcome trials [1-5]. However, new data appear in the literature every day. In 2005 a total of 63,286 publications that included the keyword ???hypertension?? appeared in the MedLine, of which 2,484 were reports of clinical trials. Only few of these trials are expected to change current recommendations for the management of hypertension in clinical practice. This document presents several issues in the current hypertension guidelines that the author believes need to be modified mainly because of new information from recent clinical trials
Admissions to the Coronary Care Unit (CCU): Comparison With International Data
Get PDFIn the beginning of the 20th century, cardiac diseases were responsible for less than the 10% of deaths in the entire world. At the end of the same century, it was found that they were responsible for 45% of total mortality in the developed countries, for 55% of total mortality in the emerging economically societies, while in the developing societies they accounted for 25% of all deaths. In America, 2.7% per year reduction of cardiac mortality was achieved during the past decade. We should underline that the rate of reduction was not uniform all over America. In Europe, big inequality exists among various countries regarding the magnitude and the time trend of mortality from cardiovascular disease. Eastern European countries have higher mortality rates than the westerners and the same is true for northerners compared to southerners. In Greece, according to the National Statistics Service2, cardiac diseases constituted the leading cause of deaths over the past decade. During the year 2007, 529 patients were hospitalized in the Coronary Care Unit (CCU) of ???Evangelismos?? Hospital in Athens. The medical care of these patients was undertaken by the staff of the 1st Cardiology Department. Based on data derived from this patient population, we present a comparison against international data, in terms of their basic epidemiological features
Thoracic Aortic Aneurysm: Reading the Enemy’s Playbook
Get PDFImagine if a sports team were able to read the opposing team’s playbook; this would be a boon of major proportions. Aortic diseases represent a virulent opponent for cardiac specialists and for our patients. Over the last 10 years, at the Yale Center for Thoracic Aortic Disease, we have made a concerted effort to learn more about the natural history of aortic diseases based on a data set including information on 3000 patients and 9000 years of patient follow-up and 9000 serial imaging studies. This analysis has given us glimpses into the playbook of thoracic aortic diseases; these glimpses have corrolaries in terms of the appropriate role and timing of surgical intervention. Aortic dissection is one of the most catastrophic acute natural events that can befall the human being. The pain of this disorder is often described by those affected as the most severe pain imaginable. Because acute aortic dissection often masquerades as a heart attack, its true incidence is often underestimated. If a middle-aged or elderly person presents to the emergency room with acute onset of chest pain, clutches his chest, and promptly dies, he is likely to be signed out as a “myocardial infarctionâ€. In actual fact, many such presentations represent undiagnosed aortic dissections. It takes autopsy series to document the true incidence of acute aortic dissection. Such series have indicated that aortic dissection is actually the most common lethal condition affecting the human aorta, more common than the better appreciated ruptured abdominal aortic aneurysm... (excerpt
Techniques of Implantation of a Biventricular Pacing System
Get PDFCardiac resynchronization therapy (CRT) was conceived in the mid-199 0s. It offered not only atrioventricular (AV) synchronization as had previously been used in dual chamber pacing but also synchronization of the two ventricles.By pacing the region of the left ventricle (LV) with the most delayed activation, it was possible both to improve interventricular synchrony and the synchrony of the LV itself. A brief review of the current techniques achieving this purpose is attempted
The philosophy of Evidence-based Medicine
Get PDFEvidence-based Medicine is the application of the best evidence available in the care of individual patients, using mathematical estimates of probability and risk. Although elements of EBM have appeared centuries ago, the term Evidence-based Medicine has been used for 10 years only. The spread of EBM followed studies which had shown that in contemporary medicine a significant proportion of interventions, although they are considered as the standard of care, have not proven efficacy. The two principles of EBM are that evidence alone is not enough for clinical decision making and that there is a hierarchy of evidence. Evidence-based medicine can be practiced in up to five steps i.e. formulating answerable clinical questions, searching for the best available evidence, critically appraising the evidence, applying the evidence in clinical situations and evaluating one’s effectiveness and efficiency. One does not have to go through all steps in practicing EBM, e.g. there now exist the so called secondary publications which are systematic reviews or meta-analyses of all available studies on a clinical problem or journals entirely devoted in appraisal of original studies. Notwithstanding the “success” of EBM there is a strong current of criticism on subjects practical and philosophical alike. The strongest point against EBM however is that there is no evidence that practicing EBM improves patients’ outcomes. In our opinion, EBM is a very useful instrument with wide-ranging applications in the practice of medicine. However EBM is neither a new scientific field nor a paradigm shift in contemporary medicine. As an empirical approach to clinical problems, EBM does not produce scientific knowledge and therefore it should not be given more room than it deserves, neglecting basic or clinical research. “...between man and angel there is this difference, that an angel perceives the truth by simple apprehension, whereas man becomes acquainted with a simple truth by a process from manifold data” Thomas Aquinas, Summa Theologica
Individualized Tailoring of Hypolipidemic Pharmacological Treatment
Get PDFThe validation of the lipid hypothesis, which pertains to the relationship between dyslipidemia and atherogenesis, has established the central role of hypolipidemic treatment in the frontline of primary and secondary prevention of coronary artery disease. However, the complexity of the lipoprotein disorders, which are usually associated with more than one biochemical abnormalities, and the availability of several hypolipidemic agents in the existing therapeutic armamentarium with combined beneficial effects of variable intensity on several lipoproteins, have stressed the need for the development and implementation of easily applicable therapeutic algorithms which will enable the individualized tailoring of hypolipidemic management with maximal efficiency and safety. One such algorithm of individualized tailoring of hypolipidemic therapy is being proposed in this brief overview
Diastolic Heart Failure: Current Data
Get PDFSeveral definitions of diastolic heart failure have been proposed. One definition is, ???a condition resulting from an increased resistance to filling of one or both ventricles leading to symptoms of congestion due to an inappropriate upward shift of the diastolic pressure ???volume relation (that is during the terminal phase of the cardiac cycle)??. Another proposed definition is that diastolic heart failure is a condition in which the ???ventricular chamber is unable to accept an adequate volume of blood during diastole at normal diastolic pressures and at volumes sufficient to maintain an appropriate stroke volume??. These definitions describe pathophysiology and functional abnormalities but cannot be applied in clinical practice. The widely used clinical definition of diastolic heart failure is, ???a clinical condition characterized by the presence of signs and symptoms of heart failure and preserved left ventricular ejection fraction??. Based on this definition, diastolic heart failure is also termed ???heart failure with preserved ejection fraction??
Long RP Tachycardia with Atrioventricular Block. What is the Tachycardia Mechanism?
Get PDFA 23-year-old woman underwent electrophysiological study because of a 9-year history of frequent episodes of supraventricular tachycardia. The patient had a normal baseline ECG and no structural heart disease. The baseline AH and HV intervals were 70 and 40 msec, respectively. Incremental atrial pacing and ventricular pacing reproducibly induced a narrow QRS complex tachycardia (cycle length 344 ms) with negative P-wave polarity in inferior leads and positive in V1 lead. During the tachycardia the earliest atrial activation was recorded at the ostium of the coronary sinus, where the AH and HA intervals were 95 and 237 ms, respectively (Fig. 1). What is the mechanism of this tachycardia